Managed Care 101: Boot-camp for Healthcare Entrepreneurs

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Күн бұрын

Healthcare flow of funds explained.
Managed Care 101 for healthcare entrepreneurs seeking to do business in the California market. Session led by Alex Yarijanian, CEO Carenodes.
Agenda distributed:
"Everyone should be able to walk out of this session feeling empowered by having learned basic flow of funds (starting at the payer) and reimbursement structures along the healthcare delivery value chain.
Managed Care Boot-camp for Healthcare Entrepreneurs, 'pilot' session designed to impart otherwise difficult to synthesize knowledge with the following objectives:
1. Bend the learning curve of entrepreneurs in healthcare
2. Provide a framework to contextualize health tech business models
My aim is to help provide a framework within which you will find your place in the business value chain.
You should be able to better refine your understanding of what 'buckets', and mechanisms, of funding you should pursue and trigger so as to index your business accordingly. Trends, current industry practices, and changes set to be effective in the future will be weaved into the session so as to contextualize the material.
Agenda Items:
Essential concepts:
• 6 functional areas
• Volume to Value
I. Managed Care Mindset
• Managed care: utilization management
• Volume shift to value
• Quality measured
○ Patient experience
○ Clinical outcomes
II. Lines of Business aka 'LOB' (funding source)
• Medicare (Traditional Medicare and Medicare Advantage, prts ABCD)
• Medicaid (managed Medicaid, state / federal, Medi-Cal)
• Duals (Medicare and Medicaid beneficiaries)
• Commercial (on exchange, off exchange)
III. Products (benefit designs)
• Spectrum of 'utilization management': HMO, PPO, POS, EPO, FFS
IV. Difference between 'LOB' vs 'product'.
V. Main Reimbursement structures (from payer to provider)
• Fee for service (FFS)
• Value based payment: upside, upside/downside
• Predominate California Market Structure, determine who is at risk
○ Capitation
○ Delegation
○ Risk based (capitations and delegation of functions by the health plan to a third party): global-risk, shared risk, dual risk
VI. Q/A"
www.carenodes.com/healthcare-...

Пікірлер: 20

@elbissg 4 жыл бұрын

Very helpful thanks for this

@alexyarijanian6716 4 жыл бұрын

Great I'm glad you found this helpful

@sawang1275 3 жыл бұрын

I cannot thank you enough for sharing your knowledge on KZfaq! What is the difference between health plans and managed care organizations? Do you use them interchangeably? Especially when talking about contracting with providers and hospitals?

@carenodes 3 жыл бұрын

What a great question. Health Plan has a more narrow definition in terms of the organizational scope and regulatory implications to which it is subjected (varies by state as well). Managed Care Organization is a broader term that includes Health Plans but can also include IPAs and similar risk-bearing organizations. Managed Care is aka controlling costs by controlling utilization of care by managing care only to 'medically necessary' services. These can be and are often used interchangeably, yes. And 95% of the time when folks use "Managed Care org" they are really referring to a Health Plan. This is no different from setting to setting in terms of nomenclature usage, it's general industry way of referring to a paying entity in a payer-provider contractual relationship/discussion. Does that help? :)

@avi5278 2 жыл бұрын

This was super informational -- thank you for making this. It's hard to see what's written on the board, is there a more in-depth outline/PDF beyond what is listed in the description?

@araratalexyarijanian2938 2 жыл бұрын

I agree it’s hard to see - try this video: kzfaq.info/get/bejne/nNafoZCSnb_bhI0.html I was able to find the following but I think it’s a more truncated version vs a more detailed one. Goal: Everyone should be able to walk out of this session feeling empowered by having learned basic flow of funds (starting at the payer) and reimbursement structures along the healthcare delivery value chain. Managed Care Bootcamp for Healthcare Entrepreneurs is a 'pilot' session designed to impart otherwise tribal, 'insider', knowledge so as to bend the learning curve of entrepreneurs in healthcare. Trends, current industry practices, and changes set to be effective in the future will be weaved into the session so as to contextualize the material. Agenda Items: I. Managed Care Mindset II. Lines of Business aka 'LOB' (funding source) Medicare (Traditional Medicare and Medicare Advantage, prts ABCD) Medicaid (managed Medicaid, state / federal, Medi-Cal) Duals (Medicare and Medicaid beneficiaries) Commercial (on exchange, off exchange) III. Products (benefit designs) HMO, PPO, POS, EPO, FFS IV. Difference between 'LOB' vs 'product'. V. Main Reimbursement structures (from payer to provider... eventually) Fee for service (FFS) Value based payment: upside, upside/downside Predominate California Market Structure, determine who is at risk Capitation Delegation Risk based (capitations and delegation of functions by the health plan to a third party): global-risk, shared risk, dual risk VI. Q/A

@carolinerono6569 3 жыл бұрын

Can an organization choose to manage the care (MA or MC) for particular illness eg for ventilator dependent or diabetics only?

@carenodes 3 жыл бұрын

Are you asking whether a healthcare provider can choose to implement a disease- or condition-specific care management model?

@carolinerono6569 3 жыл бұрын

@@carenodes Yes. For example, I would like to manage the care for at home ventilator dependant patients only. Is it possible to get registered/certified as a managed care provider in let's say Texas?

@carenodes 3 жыл бұрын

@@carolinerono6569 as a health care provider you can choose to focus on a specific condition or disease and further focus on treating those conditions at home granted whatever certifications / training / credentialing you might require in the area in which the patient is based. You can do so as long as you follow all requirements and regulations. I don't see why not.

@carolinerono6569 3 жыл бұрын

@@carenodes Thanks. This has been helpful. Why does the paper work to register as a point of service healthcare provider have to be so tedious and impossible to navigate by oneself 😅😅. Thank you once again.

@carenodes 3 жыл бұрын

@@carolinerono6569 Are you using NPPES to register the taxonomy as POS or is this a state level thing?